HomeMy WebLinkAboutSeptic Pumping Slip - 55 CRICKET LANE 1/17/2017Corn onweafth of Massachusetts
City/Town of
Ote ecord
TOWN OF NORTH ANDOVER
Fo 4 HEALTH DEPARTMENT
DEP has provided this form for useby local Boards Of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
JAN 7 20
A. Facility nfor ation
1. System Location: Left / Right front of hous , aft RightcouSe) Left/ right side of house, Left /
Right side of building, Left / Right frOnt of bui ng, Left / ghlrear bf building, Under deck
2. System Owner
Name'
Address (if different from location)
City/Town
1. Date of Pumping
Date
3 Typebf system':
LJ Other (describe):
4: Effluent Tee Filter present? 0 Yap ccri If yes, was it cleaned? 0 Yes 0 No,
Cesspool(s)
2. Quantity Pumped:
ra,Sep-fnk
Gallons
Tight Tank
' 5. Condition of System:
6; System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
Lowell Waste Wate
Sigrtufe Hauls
-ue
F5821
Vehicle License Number
Da
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